Unwarranted clinical variation in health care: Definitions and proposal of an analytic framework

Real-world evidence for factors associated with maintenance treatment practices among US adults with autoimmune hepatitis

BACKGROUND AND AIMS

While avoidance of long-term corticosteroids is a common objective in the management of autoimmune hepatitis (AIH), prolonged immunosuppression is usually required to prevent disease progression. This study investigates the patient and provider factors associated with treatment patterns in US patients with AIH.

APPROACH AND RESULTS

A retrospective cohort of adults with the incident and prevalent AIH was identified from Optum's deidentified Clinformatics Data Mart Database. All patients were followed for at least 2 years, with exposures assessed during the first year and treatment patterns during the second. Patient and provider factors associated with corticosteroid-sparing monotherapy and cumulative prednisone use were identified using multivariable logistic and linear regression, respectively.The cohort was 81.2% female, 66.3% White, 11.3% Black, 11.2% Hispanic, and with a median age of 61 years. Among 2203 patients with ≥1 AIH prescription fill, 83.1% received a single regimen for >6 months of the observation year, which included 52.2% azathioprine monotherapy, 16.9% azathioprine/prednisone, and 13.3% prednisone monotherapy. Budesonide use was uncommon (2.1% combination and 1.9% monotherapy). Hispanic ethnicity (aOR: 0.56; p = 0.006), cirrhosis (aOR: 0.73; p = 0.019), osteoporosis (aOR: 0.54; p =0.001), and top quintile of provider AIH experience (aOR: 0.66; p = 0.005) were independently associated with lower use of corticosteroid-sparing monotherapy. Cumulative prednisone use was greater with diabetes (+441 mg/y; p = 0.004), osteoporosis (+749 mg/y; p < 0.001), and highly experienced providers (+556 mg/y; p < 0.001).

CONCLUSIONS

Long-term prednisone therapy remains common and unexpectedly higher among patients with comorbidities potentially aggravated by corticosteroids. The greater use of corticosteroid-based therapy with highly experienced providers may reflect more treatment-refractory disease.

Please mind the gap between guidelines & behavior change: A systematic review and a consideration on effectiveness in healthcare

BACKGROUND & OBJECTIVE

This systematic review evaluates the impact of guidelines on healthcare professionals' behavior and explores the resulting outcomes.

METHODS

Using PRISMA methodology, Scopus and Web of Science databases were searched, yielding 624 results. After applying inclusion criteria, 67 articles were selected for in-depth analysis.

RESULTS

The studies focused on key clusters: Target behaviors, Effectiveness, Research designs, Behavioral frameworks, and Publication outlets. Prescription behavior was the most studied (58.2 %), followed by other health-related behaviors (31.3 %) and hygiene practices (10.4 %). Significant behavior changes were reported in 46.3 % of studies, with 17.9 % showing negative effects, and 22.4 % reporting mixed results. Quantitative methods dominated (56.8 %), while qualitative methods (19.4 %) and review designs (13.4 %) were less common. Theoretical Domain Framework (TDF) and Behavior Change Wheel (BCW) were frequently used frameworks, with the UK and the USA contributing most studies. Medical doctors (44.8 %) were the primary participants, followed by general healthcare providers (37.3 %).

CONCLUSIONS

The study highlights the varied effectiveness of guidelines, with prescription behavior being the most investigated. Guidelines influenced behavior positively in less than half of the cases, and doctors were the primary focus, rather than nurses. The complexity of interventions suggests a need for further research to develop more effective behavioral interventions and to standardize methodological approaches to reduce clinical variation in healthcare.

The Supreme Court's decision in McCulloch v Forth Valley Health Board: Does it condone healthcare injustice?

The UK Supreme Court's recent judgement in McCulloch v Forth Valley Health Board clarifies the standard for the identification of 'reasonable' alternative medical treatments. The required standard is that of a reasonable doctor: treatments that would be accepted as proper by a responsible body of medical opinion. Accordingly, the assessment of consent involves a two-stage test: first, a 'reasonable doctor' test for identifying alternative treatments; followed by a 'reasonable person in the patient's position' test for identifying the material risks of these reasonable alternative treatments. The separation of consent into two stages is consistent with not only a certain conception of freedom but also a nuanced construct of respect for autonomy that has a normative base. Furthermore, reliance on a reasonable doctor in the first stage is in keeping with a sociological account of medical professionalism, which posits that only doctors, and none others, can determine what is a proper treatment. Yet, reliance on a reasonable doctor permits a plurality of standards for reasonableness, because differences in opinion among doctors are pervasive. The reasons for some differences might be acceptable as unavoidable imperfections in medical decision-making to a reasonable person. But reasons for other differences might be objectionable; and the resultant inequalities in medical treatments would be considered unfair. One solution is to make the plurality of reasonable alternatives available to the patient, but this would introduce practical uncertainty and it is rejected by the Court. The Court's approach may be pragmatic; however, it seems to allow avoidable injustice in healthcare.

What next for the Australian Atlas of Healthcare Variation series? Focusing the system on appropriate and sustainable health care

Mapping, identifying and reducing unwarranted healthcare variation is integral to improving the appropriateness of care - minimising wasteful or unnecessary care and redirecting care to those who could benefit most (J Eval Clin Pract 26: 687-696, 2020). The Australian Atlas of Healthcare Variation series has examined variation in healthcare use since 2015. The findings reported in the Atlas series have led to important system changes. National safety and quality standards, mandatory for all hospitals and day procedure services, now require health service organisations to monitor and investigate variation and address unwarranted variation. Clinical care standards have been developed for clinical conditions in which the Atlas series has identified considerable variation. But the overuse of low-value care and underuse of high-value care persists, as suggested by the marked variation the Atlas series continues to uncover. We must now develop an approach that systematically links reporting of data and investigation of variation with a suite of responses to address unwarranted variation. This paper focuses on efforts to reduce low value-care, so that resources can be redirected to supporting high-value care as well as reducing waste and cutting carbon emissions from health care (Med J Aust 216: 67-68, 2022).

Equity and center variation in listing status exceptions for pediatric heart transplant candidates since pediatric review board implementation

BACKGROUND

A pediatric national heart review board (NHRB) and exception guidance document to standardize decision-making were implemented in 2021 to reduce variability and ensure equity in status exceptions for pediatric candidates. We evaluated the hypothesis that these changes decreased center variability and racial disparities within the granted exceptions.

METHODS

Guidance document and pediatric NHRB were operational by February and June 2021, respectively. Candidates were stratified by listing date into: Era 1, pre-policy changes (July 2018 - June 2020) and Era 2, post-policy changes (July 2021 - June 2023). Mixed effects logistic regression models evaluated individual and center-level predictors of receiving status 1A and 1B exceptions (E) pre- and post-policy implementation.

RESULTS

Of 1,275 Era 1 listees, 15% received a 1A(E), with significant center variation. Black listees had lower likelihood of receiving 1A(E) (OR 0.57 [95% CI 0.34 - 0.94]), controlling for age, diagnosis, and center effects. Among 1,369 Era 2 listees, 14% received status 1A(E). Race was not associated with 1A(E), when controlling for the same variables, and center effect was not significant. While children listed 1B(E) increased from 12% to 16% from Era 1 to Era 2, in both eras, Black children were less likely to receive 1B(E) (OR 0.56 [95% CI 0.33 - 0.94) in Era 1, and 0.56 [0.34 - 0.91]) in Era 2). Center effect was significant in both eras.

CONCLUSIONS

Since implementing exception guidance and a pediatric review board, variation by center and patient race/ethnicity in 1A exceptions has been reduced. Center variation and racial disparities persist among 1B exceptions.

Unnecessary care in orthopaedic surgery

Unnecessary care, where the potential for harm exceeds the potential for benefit, is widespread in medical care. Orthopaedic surgery is no exception. This has significant implications for patient safety and health care expenditure. This narrative review explores unnecessary care in orthopaedic surgery. There is wide geographic variation in orthopaedic surgical practice that cannot be explained by differences in local patient populations. Furthermore, many orthopaedic interventions lack adequate low-bias evidence to support their use. Quantifying the size of the problem is difficult, but the economic burden and morbidity associated with unnecessary care is likely to be significant. An evidence gap, evidence-practice gap, cognitive biases, and health system factors all contribute to unnecessary care in orthopaedic surgery. Unnecessary care is harming patients and incurring high costs. Solutions include increasing awareness of the problem, aligning financial incentives to high value care and away from low value care, and demanding low bias evidence where none exists.

When words are your scalpel, what and how information is exchanged may be differently salient to assessors

PURPOSE

Variable assessments of learner performances can occur when different assessors determine different elements to be differently important or salient. How assessors determine the importance of performance elements has historically been thought to occur idiosyncratically and thus be amenable to assessor training interventions. More recently, a main source of variation found among assessors was two underlying factors that were differently emphasised: medical expertise and interpersonal skills. This gave legitimacy to the theory that different interpretations of the same performance may represent multiple truths. A faculty development activity introducing assessors to entrustable professional activities in which they estimated a learner's level of readiness for entrustment provided an opportunity to qualitatively explore assessor variation in the context of an interaction and in a setting in which interpersonal skills are highly valued.

METHODS

Using a constructivist grounded theory approach, we explored variation in assessment processes among a group of palliative medicine assessors who completed a simulated direct observation and assessment of the same learner interaction.

RESULTS

Despite identifying similar learner strengths and areas for improvement, the estimated level of readiness for entrustment varied substantially among assessors. Those who estimated the learner as not yet ready for entrustment seemed to prioritise what information was exchanged and viewed missed information as performance gaps. Those who estimated the learner as ready for entrustment seemed to prioritise how information was exchanged and viewed the same missed information as personal style differences or appropriate clinical judgement. When presented with a summary, assessors expressed surprise and concern about the variation.

CONCLUSION

A main source of variation among our assessors was the differential salience of performance elements that align with medical expertise and interpersonal skills. These data support the theory that when assessing an interaction, differential salience for these two factors may be an important and perhaps inevitable source of assessor variation.

Consensus-Building Processes for Implementing Perioperative Care Pathways in Common Elective Surgeries: A Systematic Review

AIMS

To identify and understand the different approaches to local consensus discussions that have been used to implement perioperative pathways for common elective surgeries.

DESIGN

Systematic review.

DATA SOURCES

Five databases (MEDLINE, CINAHL, EMBASE, Web of Science and the Cochrane Library) were searched electronically for literature published between 1 January 2000 and 6 April 2023.

METHODS

Two reviewers independently screened studies for inclusion and assessed quality. Data were extracted using a structured extraction tool. A narrative synthesis was undertaken to identify and categorise the core elements of local consensus discussions reported. Data were synthesised into process models for undertaking local consensus discussions.

RESULTS

The initial search returned 1159 articles after duplicates were removed. Following title and abstract screening, 135 articles underwent full-text review. A total of 63 articles met the inclusion criteria. Reporting of local consensus discussions varied substantially across the included studies. Four elements were consistently reported, which together define a structured process for undertaking local consensus discussions.

CONCLUSIONS

Local consensus discussions are a common implementation strategy used to reduce unwarranted clinical variation in surgical care. Several models for undertaking local consensus discussions and their implementation are presented.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Advancing our understanding of consensus building processes in perioperative pathway development could be significantly improved by refining reporting standards to include criteria for achieving consensus and assessing implementation fidelity, alongside advocating for a systematic approach to employing consensus discussions in hospitals.

IMPACT

These findings contribute to recognised gaps in the literature, including how decisions are commonly made in the design and implementation of perioperative pathways, furthering our understanding of the meaning of consensus processes that can be used by clinicians undertaking improvement initiatives.

REPORTING METHOD

This review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. No patient or public contribution.

TRIAL REGISTRATION

CRD42023413817.

Regional variation in diagnostic intensity of dementia among older U.S. adults: An observational study

INTRODUCTION

Geographic variation in diagnosed cases of Alzheimer's disease and related dementias (ADRD) could be due to underlying population risk or differences in intensity of new case identification. Areas with low ADRD diagnostic intensity could be targeted for additional surveillance efforts.

METHODS

Medicare claims were used for a cohort of older adults across hospital referral regions (HRRs). ADRD-specific regional diagnosis intensity was measured as the ratio of expected new ADRD cases (estimated using population demographics, risk factors, and practice intensity) compared to observed ADRD-diagnosed cases.

RESULTS

Crude new ADRD diagnosis rate ranged from 1.7 to 5.4 per 100 across HRRs. ADRD-specific diagnosis intensity ranged from 0.69 to 1.47 and varied most for Black, Hispanic, and the youngest (66-74) subgroups. Across all subgroups, ADRD diagnosis intensity was associated with 2-fold difference in receiving an ADRD diagnosis.

DISCUSSION

Where one resides influences the likelihood of receiving an ADRD diagnosis, particularly among those 66-74 years of age and minoritized groups.

HIGHLIGHTS

Rate of new Alzheimer's disease and related dementias (ADRD) case identification varies geographically across the United States. Variation in case identification is greatest in Black, Hispanic, and young-old groups. Intensity of diagnosis (ie, case identification) unrelated to population risk differs across place. Likelihood of receiving an ADRD diagnosis varies 2-fold based on place of residence.

Utilization of health-related data in the regional context for health service planning in the Federal State of Brandenburg, Germany-a qualitative study

BACKGROUND

Utilizing regional health data goes hand in hand with challenges: can they be used for health planning, are they applicable to the relevant topics? The study explores current data utilization and needs of stakeholders working in regional health services planning.

METHODS

We conducted 16 semi-structured expert-interviews with stakeholders of regional health planning in Brandenburg, a federal state in the north-east of Germany, by telephone or online-meeting tools between 05/2022 and 03/2023. The data were analysed according to qualitative content analysis.

RESULTS

Utilization of data sources depends on individual knowledge and personnel resources instead of being guided by standardized procedures. Interviewees primarily use internal data; some use many different platforms, studies and reports. Regional health-related data are used for reliable health planning, to prepare resolutions, draft contracts, but also for events and requests from policy makers or the press. Challenges exist in terms of availability, awareness, and acceptance of the data, perceived applicability, the ability to use it and the utilization itself. Many regional health planners indicated they would appreciate a regional integrated cross-organizational data source if the benefits for health planning outweighed the efforts.

DISCUSSION

Actors in health planning primarily utilized their own data for planning; additional data sources are not available or the level of aggregation is too high, not known by them or are often not used due to a lack of time. A standardized regional monitoring would require the definition of indicators as well as the strengthening of cross-sectoral planning.

Implementing Oxygen Therapy in Medical Wards-A Scoping Review to Understand Health Services Protocols and Procedures

Background/Objectives: Conventional oxygen therapy (COT) is the cornerstone of management for hypoxaemia associated with acute respiratory failure (ARF) in wards. COT implementation guidance is provided in local health guidance documents (LHGDs). This study aimed to identify ward-delivered adult COT implementation LHGDs in Australian health services and assess their content and accuracy. Methods: A scoping review was conducted on 1 May 2022 and updated on 19 December 2023 to identify public health services COT LHGDs. Data were extracted and analysed regarding COT initiation, monitoring, maintenance and weaning, and management of clinical deterioration. Results: Thirty-seven included LHGDs, and eleven referenced the Australian COT guidelines. A definition in the LHGDs for hypoxaemia is that any oxygen saturation (SpO2) or arterial blood gas (ABG) is rare. None required ABG prior to COT initiation. Twenty-nine provided target SpO2 aims for initiation and maintenance. Fifteen did not specify the criteria for clinical review. Nine LHGDs provided guidance on weaning. Conclusions: There was considerable variation in the structure and content of COT LHGDs in Australian health services. Variations and limited guideline concordance of LHGDs may impact the quality and safety of health care. Considerations for future research include the development and implementation of standardised core LHGD recommendations for COT, as well as conducting a national oxygen audit to better measure and benchmark the safety and quality of care.

Reducing unwarranted variation: can a 'clinical dashboard' be helpful for hospital executive boards and top-level leaders?

BACKGROUND/AIM

In the past decades, there has been an increasing focus on defining, identifying and reducing unwarranted variation in clinical practice. There have been several attempts to monitor and reduce unwarranted variation, but the experience so far is that these initiatives have failed to reach their goals. In this article, we present the initial process of developing a safety, quality and utilisation rate dashboard ('clinical dashboard') based on a selection of data routinely reported to executive boards and top-level leaders in Norwegian specialist healthcare.

METHODS

We used a modified version of Wennberg's categorisation of healthcare delivery to develop the dashboard, focusing on variation in (1) effective care and patient safety and (2) preference-sensitive and supply-sensitive care.

RESULTS

Effective care and patient safety are monitored with outcome measures such as 30-day mortality after hospital admission and 5-year cancer survival, whereas utilisation rates for procedures selected on cost and volume are used to follow variations in preference-sensitive and supply-sensitive care.

CONCLUSION

We argue that selecting quality indicators of patient safety, quality and utilisation rates and presenting them in a dashboard may help executive hospital boards and top-level leaders to focus on unwarranted variation.

Patient participation in surgical wound care in acute care settings: An integrative review

BACKGROUND

Surgical site infections can significantly impact postoperative recovery. Patient participation, which involves patients actively engaging in wound care, has been linked to improved healing and reduced wound complications. However, there is limited synthesis of the literature that explores the patient's role and participation in the context of surgical wound care.

OBJECTIVE

To explore patients' perceptions of how they participate in surgical wound care, within 30 days post-operation.

DESIGN

An integrative review guided by Whittemore and Knafl's methodology. This review was registered with PROSPERO (CRD42022363669).

DATA SOURCES

Searches were conducted in Medline (Ovid), CINAHL (Complete), and EMBASE (Elsevier) databases in October 2023, supplemented by forward and backward citation searching.

REVIEW METHODS

Based on a priori eligibility criteria, two authors independently screened articles to select relevant studies. The quality of the included research articles was critically appraised using the Mixed Methods Appraisal Tool. A descriptive and thematic synthesis was used to synthesise the findings.

RESULTS

Of the 4701 records screened for titles and abstracts, 25 studies using qualitative, quantitative, and mixed-methods designs were included. Three key themes were identified. In theme 1, 'I am healing: how my wound shapes me and my journey,' physical symptoms, psychological factors and previous experiences significantly influenced patients' engagement in wound care. Theme 2, 'Taking charge of my healing: my active engagement in wound care' described how patient participation in surgical wound care goes beyond clinical procedures and can include the use of technology and holistic self-care. Finally, theme 3, 'Navigating the path to recovery: How others shape my experience' showed that effective communication is crucial for promoting participation, yet issues like inadequate information can leave patients unprepared for wound management.

CONCLUSIONS

This review highlights opportunities to personalise and prioritise a patient-oriented approach to surgical wound care. Clinicians and educators should adopt an individualised approach by tailoring patient participation based on patient factors (i.e. physical symptoms) and adopt patient-centred communication approaches. Researchers should focus on exploring approaches to self-care and technology, as these approaches may enhance patient participation in wound care.

Effectiveness of interventions to enhance shared decision-making in wound care: A systematic review

AIMS

To explore the effectiveness of interventions to enhance patient participation in shared decision-making in wound care and tissue viability.

BACKGROUND

Caring for people living with a wound is complex due to interaction between wound healing, symptoms, psychological wellbeing and treatment effectiveness. To respond to this complexity, there has been recent emphasis on the importance of delivering patient centred wound care and shared decision-making to personalise health care. However, little is known about the effectiveness of existing interventions to support shared decision-making in wound care.

DESIGN

Systematic review of interventional studies to enhance shared decision-making in wound care or tissue viability. This was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines 2020.

METHODS

Interventional primary research studies published in English up to January 2023 were included. Screening, data extraction and quality appraisal were undertaken independently by two authors.

DATA SOURCES

Medline, EMBASE, Cochrane Central Register of Controlled Trails (trials database), CINAHL, British Nursing Index (BNI), WorldCat (thesis database), Scopus and registries of ongoing studies (ISRCTN registry and clinicaltrials.gov).

RESULTS

1063 abstracts were screened, and eight full-text studies included. Findings indicate, interventions to support shared decision-making are positively received. Goal or need setting components may assist knowledge transfer between patient and clinician, and could lower short term decisional conflict. However, generally findings within this study had very low certainty due to the inconsistencies in outcomes reported, and the variation and complexity of single and multiple interventions used.

CONCLUSIONS

Future research on shared decision-making interventions in wound care should include the involvement of stakeholders and programme theory to underpin the interventions developed to consider the complexity of interventions.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Patients setting out their needs or goals and exploring patient questions are important and should be considered in clinical care.

REGISTRATION

The review protocol was prospectively registered (PROSPERO database: CRD42023389820).

NO PATIENT OR PUBLIC CONTRIBUTION

Not applicable as this is a systematic review.

The Getting It right First Time (GIRFT) programme in urology; rationale and methodology

The Getting It Right First Time (GIRFT) programme is a quality improvement initiative covering the National Health Service in England. The programme aims to standardise clinical practices and improve patient and system level outcomes by utilising data-driven insights and clinically-led recommendations. There are GIRFT workstreams for every medical and surgical specialty, including urology. Defining features of the GIRFT methodology are that it is clinically led by experienced clinicians, data-driven, and specialty specific. Each specialty workstream conducts deep-dive visits to every hospital, analysing performance data and engaging with clinicians and management to identify and share improvement priorities. For urology, GIRFT has completed deep-dive visits and published reports outlining priority areas for development. Reports include recommendations pertaining to streamlining care pathways, reducing the acuity of care environments, enhancing emergency services, optimising utilisation of outpatient services, and workforce training and utilisation. The GIRFT academy provides guides for implementing best practices specific to priority areas of care. These include important disease pathways, and GIRFT-advocated innovations such as urology investigation units and urology area networks. GIRFT offers clinical transformation, cost reduction, equity in access to care, and leaner models of care that are often more environmentally sustainable. Evaluation efforts of the programme have focussed on assessing the adoption of GIRFT recommendations, understanding barriers to change, and modelling the climate impact of advocated practices.

Regional variation in access to and quality of acute stroke care: results of Germany's Health System Performance Assessment pilot, 2014-2020

BACKGROUND

Health System Performance Assessments (HSPA) and analyses of unwarranted regional variation in health care both aim at identifying strengths and weaknesses of health systems to improve care. Applying HSPA's conceptual approach of interrelated health system dimensions (e.g., access, quality) to regional levels might help to better understand variation in care to reduce inequity and improve performance.

METHODS

We use four indicators identified and analysed in a pilot study for a German HSPA to assess variation in access to and quality of acute stroke care between Germany's 16 federal states and urban vs. rural regions from 2014 to 2020. Stroke unit (SU) density, share of the population reaching a SU within 30 min by car, share of inpatient stroke cases treated in a hospital with a SU, and inpatient mortality were computed based on hospital quality reports and discharge data covering all acute care hospitals. Inpatient mortality was adjusted for age, sex, stroke type, and comorbidities.

RESULTS

About 500 SU were identified, i.e., 2.0 per 1,000 inpatient stroke cases. Almost 95% of Germans could reach a SU hospital within 30 min (rural: 90%; urban: 99%; > 88% in all states but one). The share of inpatient stroke cases treated in a SU hospital increased to 93% with a decreasing span between rural (92%) and urban (95%) regions and between states (74-98%). Inpatient mortality stagnated around 8.5% and increased to 9.0% in 2020 (rural: 8.7%; urban: 9.2%; states: 7.0-9.7%, one outlier of 13.3%).

CONCLUSIONS

The results especially revealed varying performance patterns in access to and quality of acute stroke care between the federal states, indicating different areas for improvement which might be addressed by more targeted policy measures in the future.

What is quality in long covid care? Lessons from a national quality improvement collaborative and multi-site ethnography

BACKGROUND

Long covid (post covid-19 condition) is a complex condition with diverse manifestations, uncertain prognosis and wide variation in current approaches to management. There have been calls for formal quality standards to reduce a so-called "postcode lottery" of care. The original aim of this study-to examine the nature of quality in long covid care and reduce unwarranted variation in services-evolved to focus on examining the reasons why standardizing care was so challenging in this condition.

METHODS

In 2021-2023, we ran a quality improvement collaborative across 10 UK sites. The dataset reported here was mostly but not entirely qualitative. It included data on the origins and current context of each clinic, interviews with staff and patients, and ethnographic observations at 13 clinics (50 consultations) and 45 multidisciplinary team (MDT) meetings (244 patient cases). Data collection and analysis were informed by relevant lenses from clinical care (e.g. evidence-based guidelines), improvement science (e.g. quality improvement cycles) and philosophy of knowledge.

RESULTS

Participating clinics made progress towards standardizing assessment and management in some topics; some variation remained but this could usually be explained. Clinics had different histories and path dependencies, occupied a different place in their healthcare ecosystem and served a varied caseload including a high proportion of patients with comorbidities. A key mechanism for achieving high-quality long covid care was when local MDTs deliberated on unusual, complex or challenging cases for which evidence-based guidelines provided no easy answers. In such cases, collective learning occurred through idiographic (case-based) reasoning, in which practitioners build lessons from the particular to the general. This contrasts with the nomothetic reasoning implicit in evidence-based guidelines, in which reasoning is assumed to go from the general (e.g. findings of clinical trials) to the particular (management of individual patients).

CONCLUSION

Not all variation in long covid services is unwarranted. Largely because long covid's manifestations are so varied and comorbidities common, generic "evidence-based" standards require much individual adaptation. In this complex condition, quality improvement resources may be productively spent supporting MDTs to optimise their case-based learning through interdisciplinary discussion. Quality assessment of a long covid service should include review of a sample of individual cases to assess how guidelines have been interpreted and personalized to meet patients' unique needs.

STUDY REGISTRATION

NCT05057260, ISRCTN15022307.

Variation in Utilization of Physical Therapist and Occupational Therapist Services After Rotator Cuff Repair: A Population-Based Study

OBJECTIVE

The objective of this study was to describe the utilization of physical therapist and occupational therapist services after rotator cuff repair (RCR) and examine variation in rehabilitation characteristics by profession.

METHODS

This retrospective cohort study used the IBM MarketScan Commercial Claims and Encounters database. Eligible patients were 18 to 64 years old and had undergone outpatient RCR between 2017 and 2020. Physical therapist and occupational therapist services were identified using evaluation and treatment codes with profession-specific modifiers ("GP" or "GO"). Factors predicting utilization of formal rehabilitation and physical therapist versus occupational therapist services were examined; and univariable and multivariable analyses of days to initiate therapy, number of visits, and episode length by profession were completed.

RESULTS

Among 53,497 patients with an RCR, 81.2% initiated formal rehabilitation (93.8% physical therapist, 5.2% occupational therapist, 1.0% both services). Patients in the Northeast and West (vs the South) were less likely to receive rehabilitation (odds ratio [OR] = 0.67 to 0.70) and less likely to receive occupational therapist services (OR = 0.39). Patients living in the Midwest (versus the South) were less likely to receive rehabilitation (OR = 0.79) but more likely to receive occupational therapist services (OR = 1.51). Similarly, those living in a rural (versus urban) area were less likely to utilize rehabilitation (OR = 0.89) but more likely to receive occupational therapist services (OR = 2.21). Additionally, receiving occupational therapist instead of physical therapist services was associated with decreased therapist visits (-16.89%), days to initiate therapy (-13.43%), and episode length (-13.78%).

CONCLUSION

Most patients in our commercially insured cohort utilized rehabilitation services, with a small percentage receiving occupational therapist services. We identified profession-specific variation in utilization characteristics that warrants further examination to understand predictors and associated outcomes.

IMPACT

Variation in rehabilitation utilization after RCR, including profession-specific and regional differences, may indicate opportunities to improve standardization and quality of care.

Variations in COPD Health Care Access and Outcomes: A Rapid Review

Background

Health inequities among individuals with chronic obstructive pulmonary disease (COPD) are often associated with differential access to health care and health outcomes. A greater understanding of the literature concerning such variation is necessary to determine where gaps or inequities exist along the continuum of COPD care.

Methods

A rapid review of the published and grey literature reporting variations in health care access and/or health outcomes for individuals with COPD was completed. Variation was defined as differential patterns in access indicators or outcome measures within sociodemographic categories, including age, ethnicity, geography, race, sex, and socioeconomic status. Emergent themes were identified from the included literature and synthesized narratively.

Results

Thirty-five articles were included for final review; the majority were retrospective cohort studies. Twenty-five studies assessed variation in access to health care. Key indicators included: access to spirometry testing, medication adherence, participation in pulmonary rehabilitation, and contact with general practitioners and/or respiratory specialists. Twenty-one studies assessed variation in health outcomes in COPD and key metrics included: hospital-based resource utilization (length of stay and admissions/readmissions), COPD exacerbations, and mortality. Patients who live in rural environments and those of lower socioeconomic status had both poorer access to care and outcomes at the system and patient level. Other sociodemographic variables, including ethnicity, race, age, and sex were associated with variation in health care access and outcomes, although these findings were less consistent.

Conclusion

The results of this rapid review suggest that substantial variation in access and outcomes exists for individuals with COPD, highlighting opportunities for targeted interventions and policies.

Implementation of large, multi-site hospital interventions: a realist evaluation of strategies for developing capability

BACKGROUND

This study presents guidelines for implementation distilled from the findings of a realist evaluation. The setting was local health districts in New South Wales, Australia that implemented three clinical improvement initiatives as part of a state-wide program. We focussed on implementation strategies designed to develop health professionals' capability to deliver value-based care initiatives for multisite programs. Capability, which increases implementers' ability to cope with unexpected scenarios is key to managing change.

METHODS

We used a mixed methods realist evaluation which tested and refined program theories elucidating the complex dynamic between context (C), mechanism (M) and outcome (O) to determine what works, for whom, under what circumstances. Data was drawn from program documents, a realist synthesis, informal discussions with implementation designers, and interviews with 10 key informants (out of 37 identified) from seven sites. Data analysis employed a retroductive approach to interrogate the causal factors identified as contributors to outcomes.

RESULTS

CMO statements were refined for four initial program theories: Making it Relevant- where participation in activities was increased when targeted to the needs of the staff; Investment in Quality Improvement- where engagement in capability development was enhanced when it was valued by all levels of the organisation; Turnover and Capability Loss- where the effects of staff turnover were mitigated; and Community-Wide Priority- where there was a strategy of spanning sites. From these data five guiding principles for implementers were distilled: (1) Involve all levels of the health system to effectively implement large-scale capability development, (2) Design capability development activities in a way that supports a learning culture, (3) Plan capability development activities with staff turnover in mind, (4) Increased capability should be distributed across teams to avoid bottlenecks in workflows and the risk of losing key staff, (5) Foster cross-site collaboration to focus effort, reduce variation in practice and promote greater cohesion in patient care.

CONCLUSIONS

A key implementation strategy for interventions to standardise high quality practice is development of clinical capability. We illustrate how leadership support, attention to staff turnover patterns, and making activities relevant to current issues, can lead to an emergent learning culture.

Identification and classification of principal features for analyzing unwarranted clinical variation

RATIONALE, AIMS, AND OBJECTIVE

Unwarranted clinical variation (UCV) is an undesirable aspect of a healthcare system, but analyzing for UCV can be difficult and time-consuming. No analytic feature guidelines currently exist to aid researchers. We performed a systematic review of UCV literature to identify and classify the features researchers have identified as necessary for the analysis of UCV.

METHODS

The literature search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We looked for articles with the terms 'medical practice variation' and 'unwarranted clinical variation' from four databases: Medline, Web of Science, EMBASE and CINAHL. The search was performed on 24 March 2023. The articles selected were original research articles in the English language reporting on UCV analysis in adult populations. Most of the studies were retrospective cohort analyses. We excluded studies reporting geographic variation based on the Atlas of Variation or small-area analysis methods. We used ASReview Lab software to assist in identifying articles for abstract review. We also conducted subsequent reference searches of the primary articles to retrieve additional articles.

RESULTS

The search yielded 499 articles, and we reviewed 46. We identified 28 principal analytic features utilized to analyze for unwarranted variation, categorised under patient-related or local healthcare context factors. Within the patient-related factors, we identified three subcategories: patient sociodemographics, clinical characteristics, and preferences, and classified 17 features into seven subcategories. In the local context category, 11 features are classified under two subcategories. Examples are provided on the usage of each feature for analysis.

CONCLUSION

Twenty-eight analytic features have been identified, and a categorisation has been established showing the relationships between features. Identifying and classifying features provides guidelines for known confounders during analysis and reduces the steps required when performing UCV analysis; there is no longer a need for a UCV researcher to engage in time-consuming feature engineering activities.

Exploration of reasons for primary care testing (the Why Test study): a UK-wide audit using the Primary care Academic CollaboraTive

BACKGROUND

Rates of blood testing have increased over the past two decades. Reasons for testing cannot easily be extracted from electronic health record databases.

AIM

To explore who requests blood tests and why, and what the outcomes of testing are in UK primary care.

DESIGN AND SETTING

A retrospective audit of electronic health records in general practices in England, Wales, Scotland, and Northern Ireland was undertaken.

METHOD

Fifty-seven clinicians from the Primary care Academic CollaboraTive (PACT) each reviewed the electronic health records of 50 patients who had blood tests in April 2021. Anonymised data were extracted including patient characteristics, who requested the tests, reasons for testing, test results, and outcomes of testing.

RESULTS

Data were collected from 2572 patients across 57 GP practices. The commonest reasons for testing in primary care were investigation of symptoms (43.2%), monitoring of existing disease (30.1%), monitoring of existing medications (10.1%), and follow up of previous abnormalities (6.8%); patient requested testing was rare in this study (1.5%). Abnormal and borderline results were common, with 26.6% of patients having completely normal test results. Around one-quarter of tests were thought to be partially or fully unnecessary when reviewed retrospectively by a clinical colleague. Overall, 6.2% of tests in primary care led to a new diagnosis or confirmation of a diagnosis.

CONCLUSION

The utilisation of a national collaborative model (PACT) has enabled a unique exploration of the rationale and outcomes of blood testing in primary care, highlighting areas for future research and optimisation.

Development of clinically meaningful quality indicators for contemporary lung cancer care, and piloting and evaluation in a retrospective cohort; experiences of the Embedding Research (and Evidence) in Cancer Healthcare (EnRICH) Program

OBJECTIVES

Lung cancer continues to be the most common cause of cancer-related death and the leading cause of morbidity and burden of disease across Australia. There is an ongoing need to identify and reduce unwarranted clinical variation that may contribute to these poor outcomes for patients with lung cancer. An Australian national strategy acknowledges clinical quality outcome data as a critical component of a continuously improving healthcare system but there is a need to ensure clinical quality indicators adequately measure evidence-based contemporary care, including novel and emerging treatments. This study aimed to develop a suite of lung cancer-specific, evidence-based, clinically acceptable quality indicators to measure quality of care and outcomes, and an associated comparative feedback dashboard to provide performance data to clinicians and hospital administrators.

DESIGN

A multistage modified Delphi process was undertaken with a Clinical Advisory Group of multidisciplinary lung cancer specialists, with patient representation, to update and prioritise potential indicators of lung cancer care derived from a targeted review of published literature and reports from national and international lung cancer quality registries. Quality indicators were piloted and evaluated with multidisciplinary teams in a retrospective observational cohort study using clinical audit data from the Embedding Research (and Evidence) in Cancer Healthcare Program, a prospective clinical cohort of over 2000 patients with lung cancer diagnosed from May 2016 to October 2021.

SETTING AND PARTICIPANTS

Six tertiary specialist cancer centres in metropolitan and regional New South Wales, Australia.

RESULTS

From an initial 37 potential quality indicators, a final set of 10 indicators spanning diagnostic, treatment, quality of life and survival domains was agreed.

CONCLUSIONS

These indicators build on and update previously available measures of lung cancer care and outcomes in use by national and international lung cancer clinical quality registries which, to our knowledge, have not been recently updated to reflect the changing lung cancer treatment paradigm.

30-day Morbidity and Mortality after Cholecystectomy for Benign Gallbladder Disease (AMBROSE): A Prospective, International Collaborative Cohort Study

OBJECTIVE

This study aimed to assess 30-day morbidity and mortality rates following cholecystectomy for benign gallbladder disease and identify the factors associated with complications.

SUMMARY BACKGROUND DATA

Although cholecystectomy is common for benign gallbladder disease, there is a gap in the knowledge of the current practice and variations on a global level.

METHODS

A prospective, international, observational collaborative cohort study of consecutive patients undergoing cholecystectomy for benign gallbladder disease from participating hospitals in 57 countries between January 1 and June 30, 2022, was performed. Univariate and multivariate logistic regression models were used to identify preoperative and operative variables associated with 30-day postoperative outcomes.

RESULTS

Data of 21,706 surgical patients from 57 countries were included in the analysis. A total of 10,821 (49.9%), 4,263 (19.7%), and 6,622 (30.5%) cholecystectomies were performed in the elective, emergency, and delayed settings, respectively. Thirty-day postoperative complications were observed in 1,738 patients (8.0%), including mortality in 83 patients (0.4%). Bile leaks (Strasberg grade A) were reported in 278 (1.3%) patients and severe bile duct injuries (Strasberg grades B-E) were reported in 48 (0.2%) patients. Patient age, ASA physical status class, surgical setting, operative approach and Nassar operative difficulty grade were identified as the five predictors demonstrating the highest relative importance in predicting postoperative complications.

CONCLUSION

This multinational observational collaborative cohort study presents a comprehensive report of the current practices and outcomes of cholecystectomy for benign gallbladder disease. Ongoing global collaborative evaluations and initiatives are needed to promote quality assurance and improvement in cholecystectomy.

Synthesis of 'joint class' curricula at high volume joint replacement centres and a preliminary model for development and evaluation

RATIONALE

Preoperative patient education through 'joint class' has potential to improve quality of care for total joint replacement (TJR). However, no formal guidance exists regarding curriculum content, potentially resulting in inter-institutional variation.

OBJECTIVE

We aimed to (a) synthesize curriculum components of 'joint classes' across high-volume institutions and (b) develop a preliminary theory of change model for development and evaluation guided by the existing curricula and related literature.

METHODS

We reviewed 'joint class' curricula from the websites of the 10 highest-volume TJR centres (by average annual 2017-2019 volume) that publicly disclosed this information. Two reviewers qualitatively compared available content and noted common categories, which were synthesized into key domains across institutions. We then reviewed the PubMed database for literature on pre-TJR patient education and education needs in the past 10 years. Drawing on our curriculum synthesis and related literature, we proposed a theory of change model: hypothesized mechanisms through which 'joint class' confers benefits to patients and health systems.

RESULTS

We identified 30 categories in our review of existing class content, which we synthesized into seven key domains: (I) Practical Elements, (II) Logistics, (III) Medical Information, (IV) Modifiable Risk Factors, (V) Expected Outcomes, (VI) Patient Role in Recovery and (VII) Enhanced Education. Variation across institutions was noted. Our preliminary model based on the curriculum synthesis and related literature on the impact of 'joint class' includes three levels: (1) Practical Elements ('joint class' accessibility and information quality), (2) Class Goals (increased health literacy, increased adherence, risk mitigation, realistic expectations, and reduced anxiety) and (3) Target Outcomes (improved clinical outcomes, positive patient experience and increased patient satisfaction).

CONCLUSION

Our synthesis identified core common topics included in pre-TJR education but also highlighted variation across institutions, supporting opportunities for standardization. Clinicians and researchers can use our preliminary model to systematically develop and evaluate 'joint classes,' with the goal of establishing a standard of care for TJR preoperative education.

Audit and feedback to reduce unwarranted clinical variation at scale: a realist study of implementation strategy mechanisms

BACKGROUND

Unwarranted clinical variation in hospital care includes the underuse, overuse, or misuse of services. Audit and feedback is a common strategy to reduce unwarranted variation, but its effectiveness varies widely across contexts. We aimed to identify implementation strategies, mechanisms, and contextual circumstances contributing to the impact of audit and feedback on unwarranted clinical variation.

METHODS

Realist study examining a state-wide value-based healthcare program implemented between 2017 and 2021 in New South Wales, Australia. Three initiatives within the program included audit and feedback to reduce unwarranted variation in inpatient care for different conditions. Multiple data sources were used to formulate the initial audit and feedback program theory: a systematic review, realist review, program document review, and informal discussions with key program stakeholders. Semi-structured interviews were then conducted with 56 participants to refute, refine, or confirm the initial program theories. Data were analysed retroductively using a context-mechanism-outcome framework for 11 transcripts which were coded into the audit and feedback program theory. The program theory was validated with three expert panels: senior health leaders (n = 19), Agency for Clinical Innovation (n = 11), and Ministry of Health (n = 21) staff.

RESULTS

The program's audit and feedback implementation strategy operated through eight mechanistic processes. The strategy worked well when clinicians (1) felt ownership and buy-in, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for proposed changes. The success of the strategy was constrained when the audit process led to (5) rationalising current practice instead of creating a learning opportunity, (6) perceptions of unfairness and concerns about data integrity, 7) development of improvement plans that were not followed, and (8) perceived intrusions on professional autonomy.

CONCLUSIONS

Audit and feedback strategies may help reduce unwarranted clinical variation in care where there is engagement between auditors and local clinicians, meaningful audit indicators, clear improvement plans, and respect for clinical expertise. We contribute theoretical development for audit and feedback by proposing a Model for Audit and Feedback Implementation at Scale. Recommendations include limiting the number of audit indicators, involving clinical staff and local leaders in feedback, and providing opportunities for reflection.

The unfulfilled promises of electronic health records

We provide a brief update on the current evidence on electronic health records' benefits, risks, and potential harms through a rapid narrative review. Many of the promised benefits of electronic health records have not yet been realised. Electronic health records are often not user-friendly. To enhance their potential, electronic health record platforms should be continuously evaluated and enhanced by carefully considering feedback from all stakeholders.

Periop 101: Improving Perioperative Nursing Knowledge and Competence in Labor and Delivery Nurses Through an Evidence-Based Education and Training Program

INTRODUCTION

To reach the highest levels of health care quality, all nurses providing intraoperative care to surgical patients should have a firm grasp of the complex knowledge, skills, and guidelines undergirding the perioperative nursing profession. In military treatment facilities, either perioperative registered nurses or labor and delivery (L&D) nurses provide skilled intraoperative nursing care for cesarean deliveries. However, L&D and perioperative nurses occupy vastly different roles in the continuum of care and may possess widely differing levels of surgical training and experience.

MATERIALS AND METHODS

The purpose of this project was to improve surgical care quality by standardizing and strengthening L&D nurse perioperative training, knowledge, and competence. Our population, intervention, comparative, and outcome question was, "For labor and delivery nurses of a regional military medical center (P), does implementing an evidence-based training program (I), as compared to current institutional nursing practices (C), increase nursing knowledge and perioperative nursing competence (O)?" We implemented Periop 101: A Core Curriculum-Cesarean Section training for 17 L&D nurses, measured knowledge using product-provided testing, and assessed competence using the Perceived Perioperative Competence Scale-Revised.

RESULTS

We found that perioperative nursing knowledge and competence significantly improved and were less varied among the nurses after completing the training program. Nurses demonstrated the greatest knowledge area improvements in scrubbing, gowning, and gloving; wound healing; and sterilization and disinfection, for which median scores improved by more than 100%. Nurses reported significantly greater perceived competence across all six domains of the Perioperative Competence Scale-Revised, with the largest improvements realized in foundational skills and knowledge, leadership, and proficiency.

CONCLUSIONS

We recommend that health care leaders develop policies to standardize perioperative education, training, and utilization for nurses providing intraoperative care to reduce clinician role ambiguity, decrease inefficiencies, and enhance care.

Variation in Anesthesiology Provider-Volume for Complex Gastrointestinal Cancer Surgery: A Population-Based Study

OBJECTIVE

Examine between-hospital and between-anesthesiologist variation in anesthesiology provider-volume (PV) and delivery of high-volume anesthesiology care.

BACKGROUND

Better outcomes for anesthesiologists with higher PV of complex gastrointestinal cancer surgery have been reported. The factors linking anesthesiology practice and organization to volume are unknown.

METHODS

We identified patients undergoing elective esophagectomy, hepatectomy, and pancreatectomy using linked administrative health data sets (2007-2018). Anesthesiology PV was the annual number of procedures done by the primary anesthesiologist in the 2 years before the index surgery. High-volume anesthesiology was PV>6 procedures/year. Funnel plots to described variation in anesthesiology PV and delivery of high-volume care. Hierarchical regression models examined between-anesthesiologist and between-hospital variation in delivery of high-volume care use with variance partition coefficients (VPCs) and median odds ratios (MORs).

RESULTS

Among 7893 patients cared for at 17 hospitals, funnel plots showed variation in anesthesiology PV (median ranging from 1.5, interquartile range: 1-2 to 11.5, interquartile range: 8-16) and delivery of HV care (ranging from 0% to 87%) across hospitals. After adjustment, 32% (VPC 0.32) and 16% (VPC: 0.16) of the variation were attributable to between-anesthesiologist and between-hospital differences, respectively. This translated to an anesthesiologist MOR of 4.81 (95% CI, 3.27-10.3) and hospital MOR of 3.04 (95% CI, 2.14-7.77).

CONCLUSIONS

Substantial variation in anesthesiology PV and delivery of high-volume anesthesiology care existed across hospitals. The anesthesiologist and the hospital were key determinants of the variation in high-volume anesthesiology care delivery. This suggests that targeting anesthesiology structures of care could reduce variation and improve delivery of high-volume anesthesiology care.

Survival of patients with colorectal liver metastases treated with and without preoperative chemotherapy: Nationwide propensity score-matched study

INTRODUCTION

Routine treatment with preoperative systemic chemotherapy (CTx) in patients with colorectal liver metastases (CRLM) remains controversial due to lack of consistent evidence demonstrating associated survival benefits. This study aimed to determine the effect of preoperative CTx on overall survival (OS) compared to surgery alone and to assess hospital and oncological network variation in 5-year OS.

METHODS

This was a population-based study of all patients who underwent liver resection for CRLM between 2014 and 2017 in the Netherlands. After 1:1 propensity score matching (PSM), OS was compared between patients treated with and without preoperative CTx. Hospital and oncological network variation in 5-year OS corrected for case-mix factors was calculated using an observed/expected ratio.

RESULTS

Of 2820 patients included, 852 (30.2%) and 1968 (69.8%) patients were treated with preoperative CTx and surgery alone, respectively. After PSM, 537 patients remained in each group, median number of CRLM; 3 [IQR 2-4], median size of CRLM; 28 mm [IQR 18-44], synchronous CLRM (71.1%). Median follow-up was 80.8 months. Five-year OS rates after PSM for patients treated with and without preoperative chemotherapy were 40.2% versus 38.3% (log-rank P = 0.734). After stratification for low, medium, and high tumour burden based on the tumour burden score (TBS) OS was similar for preoperative chemotherapy vs. surgery alone (log-rank P = 0.486, P = 0.914, and P = 0.744, respectively). After correction for non-modifiable patient and tumour characteristics, no relevant hospital or oncological network variation in five-year OS was observed.

CONCLUSION

In patients eligible for surgical resection, preoperative chemotherapy does not provide an overall survival benefit compared to surgery alone.

Patient-, Clinician-, and Institution-level Variation in Inotrope Use for Cardiac Surgery: A Multicenter Observational Analysis

BACKGROUND

Conflicting evidence exists regarding the risks and benefits of inotropic therapies during cardiac surgery, and the extent of variation in clinical practice remains understudied. Therefore, the authors sought to quantify patient-, anesthesiologist-, and hospital-related contributions to variation in inotrope use.

METHODS

In this observational study, nonemergent adult cardiac surgeries using cardiopulmonary bypass were reviewed across a multicenter cohort of academic and community hospitals from 2014 to 2019. Patients who were moribund, receiving mechanical circulatory support, or receiving preoperative or home inotropes were excluded. The primary outcome was an inotrope infusion (epinephrine, dobutamine, milrinone, dopamine) administered for greater than 60 consecutive min intraoperatively or ongoing upon transport from the operating room. Institution-, clinician-, and patient-level variance components were studied.

RESULTS

Among 51,085 cases across 611 attending anesthesiologists and 29 hospitals, 27,033 (52.9%) cases received at least one intraoperative inotrope, including 21,796 (42.7%) epinephrine, 6,360 (12.4%) milrinone, 2,000 (3.9%) dobutamine, and 602 (1.2%) dopamine (non-mutually exclusive). Variation in inotrope use was 22.6% attributable to the institution, 6.8% attributable to the primary attending anesthesiologist, and 70.6% attributable to the patient. The adjusted median odds ratio for the same patient receiving inotropes was 1.73 between 2 randomly selected clinicians and 3.55 between 2 randomly selected institutions. Factors most strongly associated with increased likelihood of inotrope use were institutional medical school affiliation (adjusted odds ratio, 6.2; 95% CI, 1.39 to 27.8), heart failure (adjusted odds ratio, 2.60; 95% CI, 2.46 to 2.76), pulmonary circulation disorder (adjusted odds ratio, 1.72; 95% CI, 1.58 to 1.87), loop diuretic home medication (adjusted odds ratio, 1.55; 95% CI, 1.42 to 1.69), Black race (adjusted odds ratio, 1.49; 95% CI, 1.32 to 1.68), and digoxin home medication (adjusted odds ratio, 1.48; 95% CI, 1.18 to 1.86).

CONCLUSIONS

Variation in inotrope use during cardiac surgery is attributable to the institution and to the clinician, in addition to the patient. Variation across institutions and clinicians suggests a need for future quantitative and qualitative research to understand variation in inotrope use affecting outcomes and develop evidence-based, patient-centered inotrope therapies.

EDITOR’S PERSPECTIVE

Sex differences in care complexity and cost of cardiac-related procedures as a basis for improving hospital payments systems

In this study, we estimate sex differences in care complexity and cost of cardiac-related procedures in order to demonstrate the importance of sex as a risk adjuster in a hospital payment system. We use individual visit-level data for all adult Israelis who underwent either heart valve surgery (HVS) or coronary artery bypass graft surgery (CABG) during the period 2014-2018 in publicly funded hospitals. We find that women undergoing a cardiac-related procedure are more likely to die during hospitalization, they have longer hospital stays, and overall, they are more likely to be care-complex than men. Furthermore, the cost of the surgery itself is higher for women than for men in the case of HVS (though not CABG), and the cost of the post-operative hospital stay is higher in the case of CABG (though not HVS). It is concluded that sex differences should be considered in the calculation of payment for cardiac-related procedures in order to reduce incentives for selection and reduce unwarranted variation in cardiac-care utilization and medical practice.

Rates of repeated colonoscopies to clean the colon from low-risk and high-risk adenomas: results from the EPoS trials

OBJECTIVE

High-quality colonoscopy (adequate bowel preparation, whole-colon visualisation and removal of all neoplastic polyps) is a prerequisite to start polyp surveillance, and is ideally achieved in one colonoscopy. In a large multinational polyp surveillance trial, we aimed to investigate clinical practice variation in number of colonoscopies needed to enrol patients with low-risk and high-risk adenomas in polyp surveillance.

DESIGN

We retrieved data of all patients with low-risk adenomas (one or two tubular adenomas <10 mm with low-grade dysplasia) and high-risk adenomas (3-10 adenomas, ≥1 adenoma ≥10 mm, high-grade dysplasia or villous components) in the European Polyp Surveillance trials fulfilling certain logistic and methodologic criteria. We analysed variations in number of colonoscopies needed to achieve high-quality colonoscopy and enter polyp surveillance by endoscopy centre, and by endoscopists who enrolled ≥30 patients.

RESULTS

The study comprised 15 581 patients from 38 endoscopy centres in five European countries; 6794 patients had low-risk and 8787 had high-risk adenomas. 961 patients (6.2%, 95% CI 5.8% to 6.6%) underwent two or more colonoscopies before surveillance began; 101 (1.5%, 95% CI 1.2% to 1.8%) in the low-risk group and 860 (9.8%, 95% CI 9.2% to 10.4%) in the high-risk group. Main reasons were poor bowel preparation (21.3%) or incomplete colonoscopy/polypectomy (14.4%) or planned second procedure (27.8%). Need of repeat colonoscopy varied between study centres ranging from 0% to 11.8% in low-risk adenoma patients and from 0% to 63.9% in high-risk adenoma patients. On the second colonoscopy, the two most common reasons for a repeat (third) colonoscopy were piecemeal resection (26.5%) and unspecified reason (23.9%).

CONCLUSION

There is considerable practice variation in the number of colonoscopies performed to achieve complete polyp removal, indicating need for targeted quality improvement to reduce patient burden.

TRIAL REGISTRATION NUMBER

NCT02319928.

Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O'CAFÉ trial)

BACKGROUND

Management of adults with atrial fibrillation (AF) or atrial flutter in the emergency department (ED) includes rate reduction, cardioversion, and stroke prevention. Different approaches to these components of care may lead to variation in frequency of hospitalization and stroke prevention actions, with significant implications for patient experience, cost of care, and risk of complications. Standardization using evidence-based recommendations could reduce variation in management, preventable hospitalizations, and stroke risk.

METHODS

We describe the rationale for our ED-based AF treatment recommendations. We also describe the development of an electronic clinical decision support system (CDSS) to deliver these recommendations to emergency physicians at the point of care. We implemented the CDSS at three pilot sites to assess feasibility and solicit user feedback. We will evaluate the impact of the CDSS on hospitalization and stroke prevention actions using a stepped-wedge cluster randomized pragmatic clinical trial across 13 community EDs in Northern California.

DISCUSSION

We hypothesize that the CDSS intervention will reduce hospitalization of adults with isolated AF or atrial flutter presenting to the ED and increase anticoagulation prescription in eligible patients at the time of ED discharge and within 30 days. If our hypotheses are confirmed, the treatment protocol and CDSS could be recommended to other EDs to improve management of adults with AF or atrial flutter.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05009225 .  Registered on 17 August 2021.

Trauma-Related Clinical Practice Variation in Dutch Emergency Departments

Structural insights in the use of protocols and the extent of practice variation in EDs are lacking. The objective is to determine the extent of practice variation in EDs in The Netherlands, based on specified common practices. We performed a comparative study on Dutch EDs that employed emergency physicians to determine practice variation. Data on practices were collected via a questionnaire. Fifty-two EDs across The Netherlands were included. Thrombosis prophylaxis was prescribed for below-knee plaster immobilization in 27% of EDs. Vitamin C was prescribed in 50% of EDs after a wrist fracture. Splitting of applied casts to the upper or lower limb was performed in one-third of the EDs. Analysis of the cervical spine after trauma was performed by the NEXUS criteria (69%), the Canadian C-spine Rule (17%) or otherwise. The imaging modality for cervical spine trauma in adults was a CT scan (98%). The cast used for scaphoid fractures was divided between the short arm cast (46%) and the navicular cast (54%). Locoregional anaesthesia for femoral fractures was applied in 54% of the EDs. EDs in The Netherlands showed considerable practice variation in treatments among the subjects studied. Further research is warranted to gain a full understanding of the variation in practice in EDs and the potential to improve quality and efficiency.

(Un)warranted variation in local hospital protocols for neonatal referral to the pediatrician: An explorative study in the Netherlands

BACKGROUND

Studies indicate unwarranted variation in a wide range of neonatal care practices, contributing to preventable morbidity and mortality. Unwarranted variation is the result of complex interactions and multiple determinants. One of the determinants contributing to unwarranted variation in care may be variation in local hospital protocols. The purpose of this study was to examine variation in the content of obstetric and neonatal protocols for six common indications for neonatal referral to the pediatrician: large for gestational age/macrosomia, small for gestational age/fetal growth restriction, meconium-stained amniotic fluid, vacuum extraction, forceps extraction, and cesarean birth.

METHODS

We conducted a nationwide cross-sectional study examining protocols for neonatal referral to the pediatrician in the obstetric and neonatal departments of all Dutch hospitals. Variation in protocols was analyzed between regions, between neonatal and obstetrics departments located in the same hospital, and within neonatal and obstetrics departments.

RESULTS

There was considerable variation in protocols between regions, between neonatal and obstetrics departments, and within neonatal and obstetrics departments. The results of this study showed considerable variation in recommendations for type of referral, admission, screening/diagnostic tests, treatment, and discharge. Furthermore, results generally showed lower referral thresholds in neonatal departments compared with obstetric departments, and higher referral thresholds in the eastern region of the Netherlands. We also found variation in local hospital protocols, which could not be explained by population characteristics but which may be explained by varying recommendations in existing national and international guidelines and/or lack of adherence to these guidelines.

CONCLUSIONS

To reduce unwarranted variation in local protocols, evidence-based, multidisciplinary guidelines should be developed in the Netherlands. Further research addressing knowledge gaps is needed to inform these guidelines. Attention should be paid to the implementation of evidence, and only where evidence is lacking or inconclusive should agreements be based on multidisciplinary consensus. Where protocols deviate from evidence-based guidelines because of specific local circumstances, clearer, more transparent justifications should be made. Uniformity in guidance will offer clear standards for care evaluation and provide opportunities to reduce inappropriate care.

Practice variation in opioid prescribing for non-cancer pain in Dutch primary care: A retrospective database study

BACKGROUND

Prescription opioid use has increased steadily in many Western countries over the past two decades, most notably in the US, Canada, and most European countries, including the Netherlands. Especially the increasing use of prescription opioids for chronic non-cancer pain has raised concerns. Most opioids in the Netherlands are prescribed in general practices. However, little is known about variation in opioid prescribing between general practices. To better understand this, we investigated practice variation in opioid prescribing for non-cancer pain between Dutch general practices.

METHODS

Data from 2017-2019 of approximately 10% of all Dutch general practices was used. Each year included approximately 1000000 patients distributed over approximately 380 practices. The primary outcome was the proportion of patients with chronic (>90 days) high-dose (≥90 oral morphine equivalents) opioid prescriptions. The secondary outcome was the proportion of patients with chronic (<90 oral morphine equivalents) opioid prescriptions. Practice variation was expressed as the ratio of the 95th/5th percentiles and the ratio of mean top 10/bottom 10. Funnel plots were used to identify outliers. Potential factors associated with unwarranted variation were investigated by comparing outliers on practice size, patient neighbourhood socioeconomic status, and urbanicity.

RESULTS

Results were similar across all years. The magnitude of variation for chronic high-dose opioid prescriptions in 2019 was 7.51-fold (95%/5% ratio), and 15.1-fold (top 10/bottom 10 ratio). The percentage of outliers in the funnel plots varied between 13.8% and 21.7%. Practices with high chronic high-dose opioid prescription proportions were larger, and had more patients from lower income and densely populated areas.

CONCLUSIONS

There might be unwarranted practice variation in chronic high-dose opioid prescriptions in primary care, pointing at possible inappropriate use of opioids. This appears to be related to socioeconomic status, urbanicity, and practice size. Further investigation of the factors driving practice variation can provide target points for quality improvement and reduce inappropriate care and unwarranted variation.

Clinical pharmacists' reported approaches and processes for undertaking Home Medicines Review services: A national survey

INTRODUCTION

Comprehensive medicines reviews are a strategy to reduce medicines-related harm. In Australia, Home Medicines Review services (HMRs) are provided by consultant pharmacists to community-dwelling consumers, on referral from the consumer's medical practitioner. Limited research exists on the processes undertaken by consultant pharmacists when delivering HMRs, particularly as it relates to the information types received, collected, and reported.

OBJECTIVE

Describe the types of information consultant pharmacists report receiving in HMR referrals, collect before and during consumer consultations, and include in their written reports.

MATERIALS AND METHODS

We conducted a national online survey of Australian consultant pharmacists who deliver HMRs. Participants were recruited using a broad advertising strategy, including social and traditional media platforms, and snowballing. Data were analysed descriptively.

RESULTS

Of the 248 eligible participants, 179 (72%) completed the survey. The most commonly included information in the referral was medication list (97%), the least were details of hospitalisations (8%) and specialist letters (5%). Information pertaining to hospitalisation and specialist letters were collected by 20% of participants prior to the consultation. Details of, and history from, community pharmacy was the most sought information prior to consultations. Less than a quarter of participants 'most of the time' or 'always' formally assess adherence using a validated instrument during the consultation. Participants commonly (80%) report consumer concerns in the written report.

CONCLUSIONS

Consultant pharmacists collect a broad variety of information, beyond medicines-related content. Written HMR reports by consultant pharmacists were often reported to be consumer-centric.

Barriers to self-monitoring implementation in the oral anticoagulated population: A qualitative study

AIM

This study aimed to explore and understand the barriers perceived by Italian nurses to adopting self-monitoring for managing oral anticoagulation in real-life settings.

BACKGROUND

Barriers to self-monitoring implementation for managing oral anticoagulation have been poorly described.

DESIGN

The study had a qualitative descriptive and exploratory design with a hybrid approach.

METHODS

A literature review was conducted to identify a priori barriers (deductive approach), while a small and semi-structured focus group discussion was performed to explore the contextual barriers experienced by Italian nurses (inductive approach). A classic content analysis technique was adopted. Data were collected in 2019.

FINDINGS

Two main categories were identified. Organizational barriers referred to the lack of inter-professional collaboration and health-care system strategies to provide clinical pathways for self-monitoring. Individual barriers encompassed professional characteristics (e.g. university background, professional knowledge, continuum education and accountability/responsibility) and patient characteristics (e.g. patient health literacy and knowledge, engagement/empowerment and educational programmes). Finally, unwarranted clinical variation in oral anticoagulation management arose as a barrier determined by organizational and individual elements.

CONCLUSIONS

The results of this study pointed out an urgent public health issue in addressing barriers influencing self-monitoring practice and in sustaining care models that might enhance the quality improvement of self-monitoring for managing oral anticoagulation.

A Quantitative Study of Decision Thresholds for Initiation of Antibiotics in Suspected Sepsis

BACKGROUND

Clinicians' decision thresholds for initiating antibiotics in patients with suspected sepsis have not been quantified. We aimed to define an average threshold of infection likelihood at which clinicians initiate antibiotics when treating a patient with suspected infection and to evaluate the influence of severity of illness and clinician-related factors on the threshold.

DESIGN

This was a prospective survey of 153 clinicians responding to 8 clinical vignettes constructed from real-world data from 3 health care systems in the United States. We treated each hour in the vignette as a decision to treat or not treat with antibiotics and assigned an infection probability to each hour using a previously developed infection prediction model. We then estimated decision thresholds using regression models based on the timing of antibiotic initiation. We compared thresholds across categories of severity of illness and clinician-related factors.

RESULTS

Overall, the treatment threshold occurred at a 69% probability of infection, but the threshold varied significantly across severity of illness categories-when patients had high severity of illness, the treatment threshold occurred at a 55% probability of infection; when patients had intermediate severity, the threshold for antibiotic initiation occurred at an infection probability of 69%, and the threshold was 84% when patients had low severity of illness (P < 0.001 for group differences). Thresholds differed significantly across specialty, highest among infectious disease and lowest among emergency medicine clinicians and across years of experience, decreasing with increasing years of experience.

CONCLUSIONS

The threshold infection probability above which physicians choose to initiate antibiotics in suspected sepsis depends on illness severity as well as clinician factors.

IMPLICATIONS

Incorporating these context-dependent thresholds into discriminating and well-calibrated models will inform the development of future sepsis clinical decision support systems. Clinician-related differences in treatment thresholds suggests potential unwarranted variation and opportunities for performance improvement.

HIGHLIGHTS

Decision making about antibiotic initiation in suspected sepsis occurs under uncertainty, and little is known about clinicians' thresholds for treatment.In this prospective study, 153 clinicians from 3 health care systems reviewed 8 real-world clinical vignettes representing patients with sepsis and indicated the time that they would initiate antibiotics.Using a model-based approach, we estimated decision thresholds and found that thresholds differed significantly across illness severity categories and by clinician specialty and years of experience.

NHS mental health services' policies on leave for detained patients in England and Wales: A national audit

WHAT IS KNOWN ON THE SUBJECT?: 'Leave' is a common occurrence for patients detained in mental health settings. The term covers multiple scenarios, for example short periods to get off the ward through to extended periods at home prior to discharge. Despite the frequency and importance of leave, there is very little research about how it is implemented and whether, and in what circumstances, it is effective. While there is legislation about leave in the Mental Health Act (1983) mental health services are free to implement their own policies or not to implement one at all. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The leave policies of NHS mental health services in England and Wales are highly inconsistent. The extent to which policies are consistent with guidance differs depending on which service is providing care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: It is very likely that, because of inconsistencies between services and policies, practice also differs. Clinicians need to understand their responsibilities in the leave process to ensure that patients are supported in their recovery journey. Policymakers need to revisit leave policies in light of evidence from this study.

ABSTRACT

INTRODUCTION: Considerable guidance is available about the implementation of leave for detained patients, but individual mental health services are free to determine their own policies.

AIM

To determine how consistent leave policies of NHS mental health services in England and Wales are with relevant guidance and legislation.

METHOD

A national audit of NHS mental health services leave policies. Data were obtained through web searching and Freedom of Information requests. Policies were assessed against 65 criteria across four domains (administrative, Responsible Clinician, types of leave and nursing). Definitions of leave-related terms were extracted and analysed.

RESULTS

Fifty-seven (91.9%) policies were obtained. There were considerable inconsistencies in how policies were informed by relevant guidance: Domain-level consistency was 72.3% (administrative), 64.0% (Responsible Clinician), 44.7% (types of leave) and 41.9% (nursing). Definitions varied widely and commonly differed from those in relevant guidance.

DISCUSSION

Mental health professionals are inconsistently supported by the policy in their leave-related practice. This could potentially contribute to inconsistent practice and leave-related patient outcomes.

IMPLICATIONS FOR PRACTICE

To ensure patients are treated fairly clinicians need to be aware of their responsibilities around leave. In some services, they will need to go beyond their organization's stated policy to ensure this occurs.

Psychological and psychosocial aspects of major trauma care: A survey of current practice across UK and Ireland

Introduction

Psychological and psychosocial impacts of major trauma, defined as any injury that has the potential to be life-threatening and/or life changing, are common, far-reaching and often enduring. There is evidence that these aspects of major trauma care are often underserved. The aim of this research was to gain insight into the current provision and operationalisation of psychological and psychosocial aspects of major trauma care across the UK and Ireland.

Methods

A cross-sectional online survey, open to health professionals working in major trauma network hospitals was undertaken. The survey had 69 questions across six sections: Participant Demographics, Psychological First Aid, Psychosocial Assessment and Care, Assessing and Responding to Distress, Clinical Psychology Services, and Major Trauma Keyworker (Coordinator) Role.

Results

There were 102 respondents from across the regions and from a range of professional groups. Survey findings indicate a lack of formalised systems to assess, respond and evaluate psychological and psychosocial aspects of major trauma care, most notably for patients with lower-level distress and psychosocial support needs, and for trauma populations that don't reach threshold for serious injury or complex health need. The findings highlight the role of major trauma keyworkers (coordinators) in psychosocial aspects of care and that although major trauma clinical psychology services are increasingly embedded, many lack the capacity to meet demand.

Conclusion

Neglecting psychological and psychosocial aspects of major trauma care may extend peritraumatic distress, result in preventable Years Lived with Disability and widen post-trauma health inequalities. A stepped psychological and psychosocial care pathway for major trauma patients and their families from the point of injury and continuing as they move through services towards recovery is needed. Research to fulfil knowledge gaps to develop and implement such a model for major trauma populations should be prioritised along with the development of corresponding service specifications for providers.

Fair admission risk prediction with proportional multicalibration

Fair calibration is a widely desirable fairness criteria in risk prediction contexts. One way to measure and achieve fair calibration is with multicalibration. Multicalibration constrains calibration error among flexibly-defined subpopulations while maintaining overall calibration. However, multicalibrated models can exhibit a higher percent calibration error among groups with lower base rates than groups with higher base rates. As a result, it is possible for a decision-maker to learn to trust or distrust model predictions for specific groups. To alleviate this, we propose proportional multicalibration, a criteria that constrains the percent calibration error among groups and within prediction bins. We prove that satisfying proportional multicalibration bounds a model's multicalibration as well its differential calibration, a fairness criteria that directly measures how closely a model approximates sufficiency. Therefore, proportionally calibrated models limit the ability of decision makers to distinguish between model performance on different patient groups, which may make the models more trustworthy in practice. We provide an efficient algorithm for post-processing risk prediction models for proportional multicalibration and evaluate it empirically. We conduct simulation studies and investigate a real-world application of PMC-postprocessing to prediction of emergency department patient admissions. We observe that proportional multicalibration is a promising criteria for controlling simultaneous measures of calibration fairness of a model over intersectional groups with virtually no cost in terms of classification performance.

Does recruiting patients to diabetes prevention programmes via primary care reinforce existing inequalities in care provision between general practices? A retrospective observational study

BACKGROUND

Primary care plays a crucial role in identifying patients' needs and referring at-risk individuals to preventive services. However, well-established variations in care delivery may be replicated in this prevention activity.

OBJECTIVE

To examine whether recruiting patients to the English NHS Diabetes Prevention Programme via primary care reinforces existing inequalities in care provision between practices, in terms of clinical quality, accessibility and resources.

METHODS

We generated annual practice-level counts of referrals across the first 4 years of the programme (June 2016 to March 2020). These were linked to 15 indicators of practice clinical quality, access and resources measured during 2018/19. We used random effects Poisson regressions to examine associations between referrals and these indicators, controlling for practice and population characteristics, for 6871 practices in England.

RESULTS

On average, practices made 3.72 referrals per 1000 population annually and rates varied substantially between practices. Referral rates were positively associated with the quality of clinical care provided. A 1 SD higher level of achievement on Quality and Outcomes Framework diabetes indicators was associated with an 11% (95% CI: 8% to 14%) higher referral rate. This positive association was consistent across all five clinical quality indicators. There was no association between referral rates and accessibility, overall payments or staffing. Associations between referrals and receiving different supplementary payments over the core contract were mixed, with 8%-11% lower referral rates for some payments but not for others.

CONCLUSION

Recruiting patients to diabetes prevention programmes via primary care reinforces existing inequalities between general practices in the clinical quality of care they provide. This leaves patients registered with practices providing lower quality clinical care even more disadvantaged. Providing additional support to lower quality practices or using alternative recruitment methods may be necessary to avoid differential engagement in prevention programmes from widening these variations and potential health inequalities further.